Nurse Education Today 36 (2016) 281286

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/nedt

Review

Barriers and enablers to the use of high-delity patient simulation

manikins in nurse education: an integrative review
Amal Z. Al-Ghareeb a,b,1, Simon J. Cooper c,2
a
b
c

Saudi Arabia Cultural Mission in Canberra, Ministry of Higher Education, Saudi Arabia
School of Nursing and Midwifery, Monash University, Berwick Campus, PO Box 1071, Narre Warren, VIC 3805, Australia
School of Nursing, Midwifery and Healthcare, Federation University Australia, Gippsland Campus, Churchill, VIC, Australia

a r t i c l e

i n f o

Article history:
Accepted 10 August 2015
Keywords:
Nursing students
Patient simulation
Human patient simulator
Manikin
Faculty nurse
Educator nurse and integrative review

s u m m a r y
Objective: This integrative review identied, critically appraised and synthesised the existing evidence on the
barriers and enablers to using high-delity human patient simulator manikins (HPSMs) in undergraduate
nursing education.
Background: In nursing education, specically at the undergraduate level, a range of low to high-delity simulations have been used as teaching aids. However, nursing educators encounter challenges when introducing new
teaching methods or technology, despite the prevalence of high-delity HPSMs in nursing education.
Design: An integrative review adapted a systematic approach.
Data source: Medline, CINAHL plus, ERIC, PsychINFO, EMBASE, SCOPUS, Science Direct, Cochrane database, Joanna
Brigge Institute, ProQuest, California Simulation Alliance, Simulation Innovative Recourses Center and the search
engine Google Scholar were searched. Keywords were selected and specic inclusion/exclusion criteria were
applied.
Inclusion criteria: The review included all research designs for papers published between 2000 and 2015 that
identied the barriers and enablers to using high-delity HPSMs in undergraduate nursing education.
Review methods: Studies were appraised using the Critical Appraisal Skills Programme criteria. Thematic analysis
was undertaken and emergent themes were extracted.
Results: Twenty-one studies were included in the review. These studies adopted quasi-experimental, prospective
non-experimental and descriptive designs. Ten barriers were identied, including lack of time, fear of technology and workload issues. Seven enablers were identied, including faculty training, administrative support
and a dedicated simulation coordinator.
Conclusion: Barriers to simulation relate specically to the complex technologies inherent in high-delity HPSMs
approaches. Strategic approaches that support up-skilling and provide dedicated technological support may overcome these barriers.
2015 Elsevier Ltd. All rights reserved.

Background
Nursing is a rehearsal profession in which undergraduate nursing
students are required to acquire numerous psychomotor skills, in
which repeated practice is required to achieve the requisite knowledge
and skill during the course of their education; students are expected to
gain knowledge, critical thinking and psychomotor skills that will enable them to make clinical judgments about care and manage complex
clinical situations (Page-Cutrara, 2014). Sufcient clinical experience
is essential; however, the limited availability of placements restricts
opportunities for clinical learning. This issue is compounded by an
E-mail addresses: amal.ghareeb@monash.edu (A.Z. Al-Ghareeb), s.cooper@
federation.edu.au (S.J. Cooper).
1
Tel.: +61 3 99047236.
2
Tel.: +61 3 5122 8032.

http://dx.doi.org/10.1016/j.nedt.2015.08.005
0260-6917/ 2015 Elsevier Ltd. All rights reserved.

increase in student numbers, limited faculty and over-crowded clinical

sites (Cant and Cooper, 2009). Fortunately, sophisticated high-delity
human patient simulator manikins (HPSMs) provide a realistic alternative (Hayden et al., 2014) in an articially created environment, with
the potential for both psychological and engineering delity (McGarry
et al., 2014).
Simulation, in general, is not a new concept with examples from
World War II relating to blue box ight training (Sanford, 2010) and
the introduction of human patient simulation in the 1960's (LevettJones and Lapkin, 2014). Simulation is described as an activity designed
to mirror situations in which the participants engage with complex stimuli and, in turn, react overtly to that stimuli (Thornton and MuellerHanson, 2004). It can range in complexity from simple case studies to
fully computerised high-delity human patient simulation manikins
(Childs and Sepples, 2006). Simulation creates an opportunity for the
learner to practice and acquire knowledge in an environment that closely

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A.Z. Al-Ghareeb, S.J. Cooper / Nurse Education Today 36 (2016) 281286

matches reality, enabling them to explore assumptions and develop psychomotor skills in a safe environment (Bong et al., 2010). For example, a
systematic review by Yuan et al. (2012) conrmed that simulation experiences are effective in improving psychomotor clinical skills, enhancing
knowledge, stimulating higher order thinking, reducing the time it takes
to reach competency and enabling safe practice.
The benets of simulation are well documented. Benets include the
development of leadership and teamwork (Endacott et al., 2014),
improved decision making and critical thinking (Rhodes and Curran,
2005), clinical skills and clinical performance benets (Alinier et al.,
2006), enhanced patient deterioration management (Cooper et al.,
2012), situation awareness improvement (Bogossian et al., 2014), and
safe medication administration (Sears et al., 2010). Simulation has also
promoted learning in caring and cultural diversity (Haas et al., 2010).
Accordingly, the benets of simulated environments have been promoted by contemporary healthcare educationalists (Thornton and MuellerHanson, 2004).
Simulation places demands on the technological ability of students
and educators because it necessitates greater engagement than other
passive forms of instruction (Miller, 1987). In nursing education, specifically at the undergraduate level, a range of low to high-delity simulations is used as teaching aids, with a proliferation of high technology
approaches (Harder et al., 2013). However, in reality nurse educators
encounter a number of challenges when introducing new teaching
and simulation approaches with limited uptake of high-delity simulation approaches such as standardised patients (actors) and high-delity
human patient simulator manikin (HPSM) (Jansen et al., 2009) and an
unwillingness to use simulation as a partial replacement for clinical
placement (Cant and Cooper, 2009; Elfrink et al., 2009; Nehring and
ashley, 2004).
Objectives
This integrative review identied, critically appraised and synthesised the existing evidence on the barriers and enablers to using highdelity human patient simulator manikins (HPSMs) in undergraduate
nursing education.
Research questions
This integrative review was undertaken to answer the following two
questions: (1) What are the barriers to using high-delity human patient
simulator manikins (HPSMs) in undergraduate nursing education?
(2) What enablers can be implemented for the effective use of highdelity human patient simulator manikins (HPSMs) in undergraduate
general nursing?
Method of the review
Criteria for considering studies
This integrative review considered all research approaches (quantitative or qualitative) from 2000 to 2015 and included studies in which
nurse educators and nursing students participated. Studies that considered other health care professionals were excluded unless data for nurse
participants were available separately. The phenomenon under interrogation was the barriers and enablers to integrating high-delity HPSMs
in undergraduate nursing education (see Table 1).
Search strategy
To make sure that the search was undertaken systematically, an initial search was undertaken in Medline, including preliminary keywords
such as: Nurse*, Nursing education, Simulat*, Human Patient Simulator
Manikin, Nurse Faculty, and Nurse educator (Table 2). This search was
continued until an overlap in the articles was observed. Following this,

Table 1
Denition of terms used in the review.
Term

Denition

Barriers

Challenges or obstacles that may cause a faculty member to question

their intention to use manikins (Davis, Kimble and Gunby, 2014;
Harder et al., 2013)
Enablers
Facilities and resources that determine the successful integration of
simulation into the nursing curricula (Kardong-Edgren et al., 2008;
Nehring and Lashey, 2010)
Fidelity
The extent to which simulation models resemble live humans in
order to achieve specic, dened objectives (Paige and Morin, 2013)
In this study we review the use of high-delity HPSM, which are
life-sized computerised manikins constructed with anatomical
features and an ability to respond to the trainee's input (Lapkin et al.,
2010). This includes products such as Laerdal SimMan, Universal
Patient Simulator SimMan, VitalMan manikins and Medical
Education Technologies manikins.
Simulation Techniques used to substitute real experience with guided experience
that replicates substantial aspects of the real world in a fully
collaborative approach (Gaba, 2004)

the title and abstract of each paper were reviewed according to the
inclusion criteria. In the second stage, a more in-depth search was undertaken using several combinations of index terms and keywords
identied from the initial literature search. The common Boolean logic
operators such as AND and OR were used to narrow the search results
and terms were truncated by using the (*) symbol. Multiple databases
were searched, including: CINAHL, ERIC, PsychINFO, EMBASE, SCOPUS,
Science Direct, Cochrane database, Joanna Brigge Institute, ProQuest
and the search engine Google Scholar. In the nal stage, the reference
lists of identied articles were searched (a practice known as snowballing). Appropriate journals were also manually searched to identify
studies that were not identied during this last stage. Further, an author
name search was conducted using the names of those known to have
conducted research related to the review. Finally, the California Simulation Alliance and Simulation Innovation Resources Center (SIRC) was
hand searched.
Search outcome
Of the 1687 references located, those studies that incorporated manikins in nursing education were retained. Non-nursing and postgraduate reports were excluded. Titles and abstracts were read by the
rst and second reviewers (A.G. and S.C.) to determine their relevance
for inclusion, resulting in a full review of 81 papers and a nal inclusion
of 21 papers (Fig. 1) (reviewed articles are summarised in Table 3).
Assessment of the methodological quality
Fourteen of the included studies adopted quantitative approaches,
ve used qualitative methodologies, and two used mixed methods.
The 21 research articles were appraised for displaying rigour in their
critical analyses, which justied their inclusion in the review. The
Table 2
Inclusion and exclusion criteria.
Inclusion criteria

Exclusion criteria

Incomplete reports in the form of

Peer-reviewed papers
opinion and comment, including
Published from 2000 to 2015
editorials and conference proceedings
Published in English
Published in any country
Empirical studies that investigate faculty barriers to the use of high-delity
HPSMs in undergraduate nursing
curricula
Empirical studies that investigate faculty enablers to the use of high-delity
HPSMs in undergraduate nursing
curricula

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283

Potentially relevant papers

(n= 1687)

Papers excluded after abstract

review
(n= 1605)

Papers retained for detailed review

(n= 81)

Papers excluded after

methodological review
(n=0)

Papers assessed for

methodological review
(n= 21)

Excluded non-research reports

e.g. opinion, comment and
editorials
(n= 61)
Studies included in integrative
review
(n= 21)

Fig. 1. Flow chart of the integrative review selection process.

Critical Appraisal Skills Programme of the Public Health Resource Unit,

England (Solution Public Health, 2012) was used to analyse the quality
criteria for quantitative, qualitative and mixed methods studies. When
evaluated against the quality appraisal questions, all selected studies
contained rigorous and sufcient methodological descriptions and
thus no studies were excluded.

Table 3
Searching design in Medline.
#1 exp simulation/
#2 exp Patient simulation/
#3 exp Human patient simulation/
#4 exp Human simulation technology/
#5 Manikin.mp.
#6 Simulated environment.mp.
#7 OR 1-6
#8 Nurs*.mp
#9 Nursing education.mp.
#10 Nursing program.mp.
#11 Nursing students.mp.
#12 Nursing curricula.mp.

Data abstraction and synthesis

Outcomes were categorised into common themes, using a colourcoding method to highlight similar ndings across the literature (Taylor
et al., 2006). This process involved establishing similar or connected ndings that shared common terms and meanings. The synthesis focused on
the common barriers and enablers educators face when incorporating
high technology approaches into teaching.

Results
#15 exp Nursing school/
#16 exp Nursing faculty/
#17 exp Nurse educator/
#18 exp Nurse academia/
#19 OR 15-18
#20 = 7 AND 14
#21 = 14 AND 19
#22 = 7 AND 19
#23 Limit #22 to (English language
and year=2002-2012)
#13 exp Baccalaureate student*/
#14 OR 8-13

Characteristics of the included studies

The studies were drawn from seven countries: the United States,
Canada, Australia, Japan, New Zealand, Germany, and the United
Kingdom. Most were from the United States (n = 14). All studies
related to high-delity manikins' use in nursing simulated learning
environments (SLE). One study (Bray et al., 2009) included nurse participants and other professionals. Fourteen studies explored educators' perceptions of the barriers and enablers to simulated learning (Davis et al.,
2014; Feingold et al., 2004; Foster et al., 2008; Howard, Ross, Mitchell

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A.Z. Al-Ghareeb, S.J. Cooper / Nurse Education Today 36 (2016) 281286

and Nelson, 2014; Howard et al., 2011; Kardong-Edgren et al., 2008;

Parsh, 2010; Walton et al., 2011). The remaining six surveyed educators'
and undergraduate nursing students' perceptions of the barriers and
enablers.

Table 5
Barriers identied.
Themes

Empirical sources

1) Lack of time

Miller and Bull (2011), Bray et al. (2009), Feingold

et al. (2004), Jones and Hegge (2008), Anderson et al.
(2012), Dowie and Philip (2011), and Howard et al.
(2011).
Nehring and Lashley (2004), Admason (2010), and
Jones and Hegge (2007).
Janson et al. (2009) and Akhtar-Danesh et al. (2009).

Themes
Ten barriers (Table 5) and seven enablers (Table 6) were identied.
(See Table 4.)

2) Fear of technology
(Technostress)
3) Lack of human
resources
4) Deciencies in space
and equipment

Overview of the reviewed studies

5) Lack of trained staff

High-delity HPSMs are used extensively in the education of undergraduate nursing students. They are effective in the acquisition of
knowledge and the development of critical thinking, and enhance students' satisfaction with learning. Nevertheless, the integrative review
reveals a number of barriers that nurse educators face when using
high-delity HPSMs. This includes the time required to become familiar
with the technology, to write and run realistic scenarios, and to exibly
manage the technology during teaching episodes with many claiming
frustration and technology phobia. High-delity HPSMs manikins are
sophisticated, and educators are rarely trained to use them (Dowie

6) Lack of nancial
support
7) Insufcient simulation
manikins
8) Additional workload
9) Manikin maintenance
10) Not applicable to
curriculum

Kardong-Edgren et al. (2008), Sole et al. (2012),

Nehring and Lashley (2004), and Akhtar-Danesh
(2009).
Miller and Bull (2011), Jones and Hegge (2007),
Janson et al. (2009), Feingold et al. (2004),
Kardong-Edgren et al. (2008), Howard et al. (2011),
Davis et al. (2014) and Dowie and Philip (2011).
Adamson (2010) and Sole et al. (2012).
Dowie and Philip (2011), Nehring and Lashley (2004),
and Akhtar-Danesh (2009).
Bray et al. (2009) and Arthur et al. (2011).
Adamson (2010) and Sole et al. (2012), and Nehring
and Lashley (2004).
Janson et al. (2009), Nehring and Lashley (2004), and
Dowie and Philip (2011).

Table 4
Summary of selected studies.
Author

Design

Intervention and comparison

Sample and country

Adamson (2010)

Quantitative descriptive survey

Deans and Directors and nurse educators in the USA

Anderson et al. (2012)

Quantitative descriptive survey

Arthur et al. (2011)

Quantitative cross-sectional
survey; a web based format
survey
Quantitative electronic survey

Patient simulation versus traditional

teaching methods, e.g., classroom lecture
Patient simulation versus traditional
teaching methods, e.g., classroom lecture
Patient simulation versus traditional
clinical placement
Patient simulation versus traditional
teaching methods, e.g., classroom lecture
High-delity human patient simulators

Healthcare educators who attend HPS community forums conducted

by the University over three periods in the USA
Undergraduate nursing faculty teaching in the USA

Patient simulation versus traditional

teaching methods, e.g., classroom lecture
Two standard patient scenarios using
Laerdal SimMan
Simulation exercise using high-delity
manikin and computer software

Nurse educators who teach undergraduate nursing in the UK

Bray et al. (2009)

Davis et al. (2014)
Dowie and Phillip
(2011)
Feingold et al. (2004)

Mixed methods: survey and

interview
Quantitative informal review
Quantitative survey

Foster et al. (2008)

Quantitative prospective,
Quasi-experimental
non-randomized controlled
Jones and Hegge (2007) Quantitative descriptive survey

Patient simulation versus traditional

teaching methods, e.g., classroom lecture
Jones and Hegge (2008) Quantitative descriptive survey
Patient simulation versus traditional
teaching methods, e.g., classroom lecture
Three simulation scenarios developed by
Kardong-Edgren et al.
Quantitative prospective,
the faculty using medium delity VitalSim
(2008)
descriptive non-experimental
manikins
pilot project
King et al. (2008)
Quantitative electronic survey
Patient simulation versus traditional
teaching methods, e.g., classroom lecture
Nehring and Lashley
Quantitative international survey Patient simulation versus traditional
(2004)
teaching methods, e.g., classroom lecture
Sole et al. (2012)
Akhtar-Danesh et al.
(2009)
Harder et al. (2013)
Janson et al. (2009)
Miller and Bull (2011)
Parsh (2010)
Walton et al. (2011)
Howard et al. (2011)

Quantitative and descriptive

comparative survey
Qualitative, Q methodology

Patient simulation versus traditional

teaching methods, e.g., classroom lecture
N/A

Qualitative, ethnography
Qualitative descriptive design,
online survey
Qualitative, exploratory
semi-structured interview design
Qualitative, case study
Qualitative ground theory
Mixed methods: survey and
focus group

N/A
N/A
N/A
N/A
N/A
N/A

Individuals who participated in the 8th annual simulation conference

in the USA
Head of Schools or appropriate members of staff in Australia

Undergraduate nursing students and faculty members in the USA

Non-faculty registered nurses and graduate nursing students in the
USA
Faculty members in undergraduate nursing programme in the USA
Faculty members from a Midwestern undergraduate-nursing
programme in the USA
Baccalaureate nursing students enrolled in rst year clinical course
and faculty members in the USA
Nurse faculty members from associate degree nursing programme in
the USA
Nurse faculty in universities, colleges and simulation centres that had
purchased a Medical Education Technology (MET) Human Patient
Simulator (HPS)
Deans and Directors who participated in the Florida Center of
Nursing annual educational workshop in the USA
Nurse educators in universities and colleges across Ontario, Canada
Nurse educators of undergraduate nursing programme in Canada
Nursing faculty members of undergraduate nursing programme in
the USA
Nursing faculty members of undergraduate nursing programmes in
Australia
Nursing students and nurse educators in the USA
Baccalaureate nursing students in the USA
Undergraduate nursing students and faculty members in the USA

A.Z. Al-Ghareeb, S.J. Cooper / Nurse Education Today 36 (2016) 281286

Implication for administration

Table 6
Enablers identied.
Themes

Empirical sources

1) Faculty training

Jones and Hegge (2007), Anderson et al.

(2012), and King et al. (2008).
Adamson (2010) and Bray et al. (2009).
Parsh (2010), Walton et al. (2011), and
Feingold et al. (2004).
Walton et al. (2011) and Parsh (2010).
Adamson (2010) and Walton et al. (2011).
Sole et al (2012) Davis et al. (2014) and
Howard (2012).
Parsh (2010) and Nehring and Lashley
(2004), and Dowie and Philip (2011).

2) Administration support
3) Instructor characteristics
4) Faculty teaching strategies
5) Financial incentives
6) Dedicated simulation coordinator
7) Technological support

285

Incorporating high-delity HPSMs across the curriculum has administrative implications. Findings suggest that it is not enough to purchase
equipment and request faculty use it. Adequate training, education and
administrative support are needed. For this reason, administrators must
be willing to become involved in the process and learn about incorporating simulation technology into programmes (Fox-Yong et al.,
2012). Nursing administrators should therefore be prepared to develop
an implementation plan for high-delity HPSMs (Jeffries et al., 2009),
with involvement from all staff members and with the support of faculty directors.
Implication for practice

and Philip, 2011). There is also a lack of dedicated technicians and simulation coordinators (Bray et al., 2009).
However, there are enablers which may increase the use of such
technology, including training through simulation workshops, conferences, observation, hands-on practice, and mentor feedback (King et al.,
2008). The importance of having a full-time simulation coordinator was
cited in six studies (Feingold et al., 2004; Foster et al., 2008; Howard
et al., 2011; Kardong-Edgren et al., 2008; Parsh, 2010; Walton et al.,
2011), with responsibility for teaching faculty members on how to use
technology and incorporate simulation into their courses (Howard et al.,
2011).

Discussion
High-delity HPSMs are widely available. As an innovative teaching
tool, many nursing programmes are investing in high-cost approaches
to high-delity HPSMs. Unfortunately, such approaches are undervalued
and underused (Medley and Horne, 2005), with notable barriers to integration. While researchers have recognised that nurse educators still
need to identify the barriers to adopting innovative teaching strategies, this review is a rst step in comprehensively exploring these
barriers and the key facilitators that enhance uptake of such technology. This uptake is likely to lead to improved pedagogical approaches and learning outcomes. In the current review, lack of
time was a barrier to integrating simulation into nursing curricula,
with many participants indicating that additional time would encourage them to use simulation more extensively, e.g. Tuoriniemi
and Schott-Baer (2008), and King et al. (2008).
As stated, simulation is not a new concept and nurse educators have
used simulation for many years. However, the availability of sophisticated technology is new. Consequently, over the last decade nursing
schools have begun purchasing costly equipment, in the belief that it
will assist educators to better preparing nursing students for technologically advanced health care environments (Jeffries, 2008). However,
nursing programmes considering simulation technology will need to
address faculty members' possible discomfort in using such technology
(Bray et al., 2009). Moser (2007), for example, pointed out that the
adoption of technology into teaching is complex and involves considerable time commitment, competence development and past experience.
Further, the integration of sophisticated high-delity HPSMs into nursing curricula can be daunting for both faculty and programmes due to
the steep learning curve, complex operational requirements and high
costs (Adamson, 2010; Jones and Hegge, 2007).
The ndings of this review conrm Irwin's (2011), who stated
that educators had a fear of the unknown. This fear can result in
an avoidance of the technology. Fear of technology among faculty
is well documented in the literature (Brown et al., 2006; Hanberg,
Hoadley and Brown, 2005; Scollin, 2001). Seropian et al. (2004) recommended that a simulation specialist work with faculty members
to enhance teaching.

To prepare undergraduate nursing students for the rigour of clinical

practice and to improve patient safety, educators must identify contemporary methods that enhance skills and knowledge (Blum and Parcells,
2012). High-delity HPSMs offer clear benets to students, but nursing
programmes will need to provide resources to support and educate faculty members and students (Greenberg, Loyd and Wesley, 2002). The
challenges are apparent from this review. Understanding the facilitators
to incorporating HPSMs will enhance high technology approaches in
curricula and produce positive educational outcomes. Further work is
required to produce valid and reliable instruments for exploring educators' and students' views and to develop an understanding of pedagogy
in a range of clinical simulations.
Limitations of the review
Findings are limited due to the small sample sizes in the studies
identied, statistical rigour, heterogeneous samples, and the range of
educational foci and locations. However, ndings often form a common
thread, which will inform the development and implementation of
high-delity HPSMs.
Conclusion
High-technology simulation is widely available, with many nursing
programs investing in high cost approaches. Unfortunately, such approaches are undervalued and underused (Medley and Horne, 2005)
with notable barriers to integration. Key facilitators play an important
role in enhancing the uptake of such technology, which can lead to improved pedagogical approaches and learning outcomes.
Contributions
A.G. and S.C. performed the study design; A.G., data collection and
analysis; and A.G. and S.C., article preparation.
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